Healthcare Provider Details

I. General information

NPI: 1831342880
Provider Name (Legal Business Name): PREMIER MEDICAL PEDIATRICS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E ASH ST
PERRY FL
32347-2029
US

IV. Provider business mailing address

PO BOX 719
PERRY FL
32348-0719
US

V. Phone/Fax

Practice location:
  • Phone: 850-838-2121
  • Fax: 850-838-1842
Mailing address:
  • Phone: 850-584-3278
  • Fax: 850-584-8171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LAURIE SANTANA
Title or Position: CFO
Credential:
Phone: 850-584-3278